phyiscal examination of the newborn

8/11/2019 Phyiscal Examination of the Newborn

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Newborn History and PhysicalExamination

Alissa Barcelona Christel Mendoza


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Definition

Perinatal period: 28th

wk AOG upto 7th

day afterbirth

Neonatal period: 1st28 days after birth

Very early (birth to


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Epidemiology

2/3 of all deaths < 1yr old

Mortality is highest

during the 1st 24 hrs

after birth

FETAL

Placental insufficiency

Intrauterine infectionSevere congenital

malformations (anomalies)

Umbilical cord accident

Abruptio placentae

Hydrops fetalis


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http://www.doh.gov.ph


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History

Past medical illnesses in the motherand family

Previous maternal reproductive

problems

Events in present pregnancy

Description of the labor and delivery


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Physical Examination

Requires patience, gentleness and

procedural flexibility

APGAR ScoringAPGAR Scoring 0 1 2Heart rate Absent Below 100 Over 100

Respiratory effort Absent Slow, irregular Good, crying

Muscle tone Limp Some flexion of

extremities

Active motion

Response to catheter in

nostril (tested after

oropharynx is clear)

No response Grimace Cough or sneeze

Color Blue, pale Body pink,

extremities blue

Completely pink


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Vital Signs:

HR (N 120-160 bpm), vagal

slowing may be noted

(upto 80 bpm in postdated

infants

RR (N 30-60 breaths/min)

short pauses(5-10secs)

considered normal

Apnea: cessation of

breathing >20 secs or any

duration if accompanied by

cyanosis and bradycardia

Pulse oximetry- to screen

for PDA-dependent CHD

Blood pressure- not

routine, SBP gradient bet

upper and lower ext

>10mmHgsuspect CoA

Temp N 36.4-37C (axillary)


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Anthropometrics

Head circ: N32-26cm interm infants

SGA: BW90th

percentile Length

Symmetric SGA Asymmetric SGA

Onset: early in

gestation

Brain size

corresponds withbody size

Causes:

smoking/drugs,

small maternalsize, chromosomal

anomaly, TORCH,

metabolic d/o

Onset: late in

gestation

No or minimal

effects on fetalbrain growth

Causes:

uteroplacental

insufficiency withchronic fetal

hypoxia


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General appearance:

Physical activity (active and passive tone,

posturing)

Ankle or jaw myoclonusvs convulsive

twitching

Edema: generalized vs. localized


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Skin

Plethora Jaundice Pallor Cyanosis


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Skin

Vernix caseosa


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Skin

Mottling


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Skin

Harlequin color change


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Skin

Salmon patch


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Skin

Port wine stain


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Salmon Patch (Nevus

Simplex)

Port Wine Stain

small, pale pink, ill-defined,

vascular macules

usually symmetric

glabella, eyelids, upper lip,

and nuchal area

represent localized vascular

ectasia

persist for months, most

eventually fade

macular, sharply

circumscribed, pink to

purple, larger

unilateral

head and neck

represent mature

dilated dermal

capillaries

permanent


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Mongolian spots


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Milia


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Sebaceous hyperplasia


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Milia Sebaceous hyperplasia

Keratin-filled epithelial

cysts

Present at birth

No inflammatory

component

Caused by maternal

hormones

Does not generally

appear until after 2

weeks

More yellowish


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Erythema toxicum


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Milliaria crystallina


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Skin

Transient pustular melanosis


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Skull

Molding (esp. if normal firstborn cephalic delivery) Suture lines and fontanels

Cranial synostosis:hard nonmovable ridge over the

suture Anterior fontanel: diamond-shaped, 4-6cmat birth,

usually closes at 9-18mos

Posterior fontanel: closed at birth or admits tip of finger

till 2-4 mos

3rdfontanel: trisomy 21, preterm

Craniotabes


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Large anterior fontanel

(N= 2010mm)

Achondroplasia

Apert syndrome

Athyrotic hypothyroidism

Cleidocranial dysostosis

Congenital rubellasyndrome

Hydrocephaly

Hypophosphatasia

Intrauterine growthretardation

Kenny syndrome

Osteogenesis imperfecta

Prematurity

Pyknodysostosis

Russell-Silver syndrome

Trisomies 13-, 18-, and 21

Vitamin D deficiency

rickets

Small fontanel

Microcephaly

CraniosynostosisCongenital

hyperthyroidism

Wormian bones


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Skull

Caput succedaneum Cephalhematoma Subgaleal hemorrhage

Soft tissue swellingecchymosis

Diffuse

Crosses suture lines

1-2 days

Subperiostealbleeding

Does not cross

suture lines

2wks to 3 mos

Bleeding under theaponeurosis of

occipitofrontalis muscle

2-3 wks


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Eyes

Often spontaneously open when held up and

tipped gently

Retinal hemorrhages: common w/ vacuum-

assisted deliveries, resolve by 2-4 wks

Pupillary reflex: begins at 28-30 wks AOG

Congenital glaucoma

Leukokoria


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Skull

Megalencephaly: hydrocephaly, storage

disease, achondroplasia, cerebral gigantism,

neurocutaneous syndromes, or inborn errors

of metabolism, or may be familial

Aplasia cutis congenita: atrophic or alopecic

scalp, sporadic or AD, assoc w/ Trisomy 13,

chromosome 4 deletion, or Johanson-Blizzardsyndrome


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Face

Moebius syndrome:symmetric facial palsy sec

to absence or hypoplasia of CNVII nucleus

Ears: preauricular skin tags

Nose: choanal atresia Mouth: natal or neonatal teeth, cleft palate,

Epstein pearls- accumulation of epith cells on

hard palate, retention cysts- gums, short

frenulum, sucking callus- labial tubercle which

disappears when suckling ceases


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Neck

Goiter, cystic hygroma, branchial cleft rests,

teratoma, hemangioma, SCM

hematoma/fibrosis, clavicular fracture

Congenital torticollis

Redundant skin/webbing in a female

Thyroglossal and branchial arch sinus tracts

MC neck masses in the NB are vascularmalformations, abnormal lymphatic tissue,

teratomas, cystic hydromas and dermoid cysts


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Lungs/Heart

Breathing is entirely diaphragmatic

Grunting- potentially serious CP distress/sepsis.

if benign resolves bet 30-60min after birth

Intercostal retractions: compensation for chestwall stabilization

Lung sounds are more bronchial than vesicular

due to better transmission of large airway

sounds across a thin chest


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Heart

PMI and auscultation

SVT: >220 beats/min Systolic murmurs may be heard transiently in

normal NB as ductus arteriosus is closing (flowmurmurs) or w/ mild pulmonary branch stenosis

Diastolic murmurs should always be consideredabnormal

Suspect CHDin (1)persistent murmurs, (2)O2sat 32wks AOG

CN V: facial sensation w/ rooting reflex, corneal

reflex, grimace/ change in CR or RR w/ tactile

stimulation V1-3

CN VII: check facial symmetry at rest and upon

movt(e.g. crying)


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CN VIII gross hearing, blink/startle w/ noise

CN IX,X,XII: intact if with good sucking (CN

V,VII,XII), swallowing (CN IX,X), gag reflex (CNIX,X),tongue movt (XII)

CN XI: flexion and rotation of head

Motor Exam: posture- normal term NB have aflexor attitude, preterms lie in extension; tone-

tested via traction response(pulling from supine

to prone position) if hypotonic, will show severehead lag, strength-check symmetry of

spontaneous movt


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Deep Tendon Reflexes: use index or middle

fingers; unsustained ankle clonus(upto 10 beats)

is normal

Primitive Reflexes:

Moro: carrying baby by his back and dropping

onto hand causes extension followed by flexionof upper limbs, present from birth-5mos

Grasp:stroking ulnar side of the palm causes

hand grasp, applying pressure on ball of the footcauses toe grasp, present from birth to

6mos(palmar) or 9-10mos(plantar)


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Rooting/Sucking:stroking angle of mouth causes

sucking, birth to 3 mos

Tonic neck:turning head sidewise will cause

fencing posture towards direction of head,

birth (well-developed at 1 month) upto 5-6 mos

Sensory Exam: gross response to stroking,

withdrawal, crying, grimace

phyiscal examination of the newborn

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